Temporary stomas are used to divert the faecal stream from the distal bowel to protect an anastomosis (Windsor and Conn 2008)

In 2008 there were an estimated 334,000 new cases of colorectal cancer in the European UnionWorldwide an estimated 1.24 million new cases of colorectal cancer were diagnosed in 2008Countries that have had a rapid ‘westernisation’ of diet , such as Japan, have seen a rapid increase in the incidence of colorectal cancer. Consumption of meat and dairy products in Japan increased ten-fold between the 1950s and 1990s

there are more male cases of bowel cancer in almost all age-groups up to the age of 84, after which female cases are in the majority, even though their rates are lower, as women make up a larger proportion of the elderly populationThese comprised 9,831 (62%) deaths from colon cancer and 6,077 (38%) deaths from rectal cancer (including the anus)

The occurrence of large bowel cancer is strongly related to age, with 86% of cases arising in people who are 60 years or older In Great Britain, all age groups have shown a slight increase in bowel cancer incidence rates since the mid 1970sIn the 60-69 age-group rates rose by around 20% - from around 120 cases per 100,000 in the mid 70s to around 146 cases per 100,000 in 2006Similarly, incidence rates in 70-79 age-group have also risen by 20% since the mid 70s

However, since 2006 there has been an 11% increase in incidence rates for people aged 60-69 in Britain (12.5 per cent in England). This rise is almost certainly due to the roll out of bowel cancer screening which started in England in 2006, targeting this age group, and has now been rolled-out across the whole of the UKThe NHS Bowel Cancer Screening Programme was phased in over three years in England starting in 2006 for people aged 60-69In all programmes men and women of the relevant ages are to be invited to participate every two years by using FOBT kits in their own homes and returning them to laboratories for analysis. In England people aged over the target age group can opt-in to the scheme and request a FOBT kitApproximately 2% of tests are positive and further investigation, usually by colonoscopy, is offered. Most people with a positive test result will not have cancer

Colonoscopy - allows the complete examination of the colon. It allows visualisation of the entire bowel up to the caecum (Burch 2008)CT – produces 3D images of the abdomen, giving a cross sectional view of the colon and reliably pick up lesions more than 6mm in size. It also has ability to identify lymph nodes and liver involvement. Can determine the presence of metastases, mainly in the liver and lungs (Burch 2008)MRI – Distinguishes the layers of the rectal wall, identify local spread of rectal tumours. It can show if the CRM (circumferential resection margin) is threatened. Enlarged nodes can be seen, helping the staging of rectal tumours…determines if pre-operative chemo-radiation treatment may be of benefit to the patient (Burch 2008)

The stagedescribes the extent of the cancer in the body. It is based on how far the cancer has grown into the wall of the intestine, whether or not it has reached nearby structures, and whether or not it has spread to the lymph nodes or distant organs. The stage of a cancer is one of the most important factors in determining prognosis and treatment options. Stagingis the process of finding out how far a cancer has spread. It is based on the results of the physical exam, biopsies, and imaging tests (CT or MRI scan, x-rays, PET scan, etc.),as well as the results of surgery.T describes how far the main (primary) tumor has grown into the wall of the intestine and whether it has grown into nearby areas.N describes the extent of spread to nearby (regional) lymph nodes. Lymph nodes are small bean-shaped collections of immune system cells that are important in fighting infections. M indicates whether the cancer has spread (metastasized) to other organs of the body. (Colorectal cancer can spread almost anywhere in the body, but the most common sites of spread are the liver and lungs.)Numbers or letters appear after T, N, and M to provide more details about each of these factors. The numbers 0 through 4 indicate increasing severity. The letter X means &quot;cannot be assessed because the information is not available.&quot;T categories for colorectal cancerT categories of colorectal cancer describe the extent of spread through the layers that form the wall of the colon and rectum. These layers, from the inner to the outer, include: The inner lining (mucosa)A thin muscle layer (muscularis mucosa)The fibrous tissue beneath this muscle layer (submucosa)A thick muscle layer (muscularispropria) that contracts to force the contents of the intestines alongThe thin, outermost layers of connective tissue (subserosa and serosa) that cover most of the colon but not the rectumTx: No description of the tumor&apos;s extent is possible because of incomplete information.Tis: The cancer is in the earliest stage (in situ). It involves only the mucosa. It has not grown beyond the muscularis mucosa (inner muscle layer). T1: The cancer has grown through the muscularis mucosa and extends into the submucosa.T2: The cancer has grown through the submucosa and extends into the muscularispropria (thick outer muscle layer).T3: The cancer has grown through the muscularispropria and into the outermost layers of the colon or rectum but not through them. It has not reached any nearby organs or tissues.T4a: The cancer has grown through the serosa (also known as the visceral peritoneum), the outermost lining of the intestines. T4b: The cancer has grown through the wall of the colon or rectum and is attached to or invades into nearby tissues or organs.

Enhanced recovery after surgery (ERAS) The enhanced recovery protocol aims to reduce the stress response to surgery, enabling faster recovery with a safe and early discharge. It differs from traditional post-op care where prolonged immobility and bowel rest were standard, by promoting early mobility and gut function.Starts with pre-operative patient counselling as it has been shown that patient understanding facilitates post-op recovery and aids compliance with the care pathway. The role of the specialist stoma nurse is vital.Bowel prep, traditionally patients were fasted for 6 hours prior to surgery. ERAS protocol recommends nil by mouth solids for 6 hours and NBM liquids 2 hours. The patient is given a high carbohydrate drink prior to surgery – reduces anxiety and decreases post-op insulin resistance. ERAS concentrates on prevention of pre-op dehydration. (Windsor and Conn 2008)

The standard treatment for tumours is a Low Anterior Resection with Loop IleostomyInvolved lymph nodes may be found in the mesorectum up to 3cm beyond the primary tumourLow rectal anastomoses are associated with an increased leak rate, therefore the use of a temporary loop ileostomy or colostomy is recommended (Jones, 1999)An anterior resection involves resecting a rectal tumour while preserving the anal sphincters to allow anastomosis and faecal continence. It generally involves a midline incision to allow visualisation of the bowel. Then part of the rectum and sigmoid colon is removed and the bowel ends are anastomosed (Windsor and Conn 2008)A temporary ileostomy may be required (formed in right iliac fossa) while the anastomosis is healing to prevent leakage occuring (Windsor and Conn 2008). It is usually reversed after 3 to 6 months.During a temporary loop ileostomy, a loop of the small intestine is brought onto the anterior abdominal wall to form a stoma, but the colon (large bowel) and rectum are not removed. The procedure is usually only used as a temporary measure, when it is necessary to remove part of the colon. It diverts faeces from the body above the anastomosis so it can heal without effluent passing through it. Walter’s surgery also involved the stapling of the descending colon to the remaining rectum (allows intestinal continuity and preserves continence) Burch 2008). It can be hard to achieve a secure leak-proof anastomosis, sometimes surgeons will opt to create a colostomy, however a loop ileostomy avoids traction on the anastomosis and blood supply to the descending colon is not compromised.Once the remaining colon has healed it can be reconnected to the small intestine and the stoma can then be closedThe jejunum and ileum The mucosa of the small intestine secretes approx 2000 ml of intestinal juice daily. This watery alkaline secretion (Ph 7.5 – 8.0) is rapidly reabsorbed by the villi and acts as a vehicle for the absorption of nutrients. If the loss from an ileostomy is excessive, bicarbonate can be lost from the alkaline solution and metabolic acidosis can occur. (symptoms: deep, rapid breathing in an attempt to eliminate excess acid from the body). People with a stoma need skin protection from stomal effluent. Strongly acidic or alkaline effluent can be more damaging due to pooling in the peristomal area* A colostomy is formed from the sigmoid colon, descending colon, transverse colon or caecum. Output is flatus and usually formed or soft faeces. The more distal the stoma, the more formed the faeces will beA hartmann’s procedure is also performed via midline incision, the rectal stump is sutured closed and an end colostomy is formed in the left iliac fossa, from the proximal colon (Windsor and Conn 2008) Mesorectum - the fold of peritoneum connecting the upper portion of the rectum with the sacrumColostomy - a surgical procedure in which a stoma is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place. Ileostomy - is a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out of the ileostomy and is collected in an external pouching system stuck to the skin. Ileostomies are usually sited above the groin on the right hand side of the abdomen.Operative mortality for elective surgery = &lt; 5%Anastomtic leak rate = &lt;8 % after anterior resection (&lt;4 % for other anastomosesWound infection rate = &lt;10 % after elective surgery and curative resectionRecurrence = most tumour recurrence becomes manifest in the first two years after surgery (still risk after this time)Radiotherapy given either before or after surgery decreases the rate of local recurrence of rectal cancers.

WEEK 3 - EXPLAINTelephone call and discussion with wife. Walter needs supervision and a lot of explaining. He is following instructionsWound is leaking a bitWalter is expecting the stoma to be long term – adaptingThey have been advised Stoma nurse review due 11/01/12 as outpatientWaiting for chemotherapy2nd night – bag burst at home! All over the place!1st week they were on top of it12/01/12 – now back to going out, feel normal life

A stoma, whether temporary of permanent affects patient’s lives. If there is any possibility that a stoma might be created it is crucial that this is discussed preoperatively and an appropriate siting is necessary. This can make the difference between patients having a stoma that is easy to manage or one where the site causes significant management difficulties. This is normally the role of the stoma nurse specialist. It can allow patients to wear their normal clothes, helps with appliance fit, change and aids comfort. The position is checked in the lying, sitting and standing positions. It is sited away from skin creases, scars and bony prominences, reducing the risk of appliance leakage (Windsor and Conn 2008)THE STOMA SHOULD BE SITED WHERE THE PATIENT CAN SEE (Wright and Burch 2008)Normally a one piece appliance can stay in position for 3-4 days. Complete equipment renewal is recommended at least every 7 days

Objective – standardised or non-standardised Use as baseline and outcome measureDevelop new assessment form for stoma care (adapt PADL assessment tool) and assist the stoma nurse team in the assessment of patient’s with a newly formed stoma – promoting independenceLook to adapt our PADL assessment using the stoma team form

SubjectiveSelf-report tools are not currently used in the trustAssessing quality of life – outcome measure (inpatient and outpatient follow up?) Psychological and physical well-being – facing stoma-forming surgery can be daunting and worrying. Can manifest itself in a variety of psychological responses: anger, depression, denial, repression, low self-esteem, socio-economic problems, psychosexual problems Use of both approaches may be useful as it allows for a comparison to be made between what is reported and what is observed, and therefore what is possible in terms of performanceAreas of difference may need further investigation to determine whether there are other fears, concerns or anxieties that need to be addressed

1994 – major quality of life international study set up in 16 European countries using the Quality of Life Index (Padilla 1985) - self-administered, 34 items, Quality of life in 7 domains (psychological well-being, physical well-being, body image, pain, sexual activity, nutrition, social concerns), Satisfaction in 3 domains (patient satisfaction, improvement and experience), Self-efficacy 5 items in 2 domains (self-efficacy, help and advice)Measured quality of life in stoma patients who are followed by stoma nursesAssessed evolution of QOL after surgery over time (and describe according to country)Established the role of the stoma care nurse in the rehabilitation of patientsExamples of questions: How confident are you about cleaning your stoma?, How confident are you about changing your appliance? How fearful are you about odour or leakage?The main objective of stoma care is to promote quality of life for the patient Quality of life assessment provides a quantitative measure of the patient’s subjective well-being and functional limitationsData produced can be used as an indicator of the patient’s rehabilitation (Black 2000)

The Stoma-QoL was developed by Prieto et al (2005). Coloplast provided a grant for the research which aimed to measure quality of life among people with a stoma. The questions in Stoma-QoL are outcomes of a lot of interviews with people with a stoma, whichwere carried out in several countries in order to address the issues that were most relevant inrelation to quality of life for this group of people. The following issues are covered: Concerns about sleeping, concerns about intimaterelations, concerns regarding relationships with family and close friends and concerns regarding relationships with people other than family and close friends.The questionnaire consists of 20 questions. An example of a question could be: “I worry thatthe pouch will loosen.” All the questions must be answered on a 4-point scale. The options foranswering each question are:1. Always2. Sometimes3. Rarely4. Not at allALL 20 questions must be answered in order for the questionnaire towork. Therefore, there should not be any unanswered questions. Furthermore, ONLY ONEanswer must be given for each question.The questions are very simple and it will take approximately 5-10 minutes to complete thequestionnaire.

Post-op exercises should ideally be taught in the pre-op phase. Usually consist of leg and deep breathing exercises which are taught by the physiotherapist and reinforced by the nursing staff. In addition it can be useful to perform pelvic floor exercises, arm raises, pelvic tilts, leg lifts, knee rolls, kneeling, calf raises and relaxation techniques (Wright and Burch 2008)Pre and post op physiotherapy (is leaflet already which could be updated/adapted) Stomas are mostly sited through the rectus abdominus muscle. After the surgical wound heals, the abdominal muscles are considerably weakened and need toning to regain strength and support (Burch 2008)OT/PT/TA’s collaborate with stoma team? (skills learnt in hospital may need to be adapted in the home environment and relearned)ApproachesEmpower Walter by sharing knowledge Enable Walter to change his beliefs, attitudes, confidence, skills, behaviour and decision making abilityInvolve family/loved ones, carers(Curtin, 2010)RemediationFocus on making changes in Walter himself Put strategies in place for Walter to attain new skillsIdentify Walter’s existing skills and barriers to performanceDesign strategies that develop and/or improve Walter’s abilities required for occupational performance and engagementMethods may include positioning, exercises, techniques(Curtin, 2010)Compensatory/AdaptiveFocus on changing the environment , tools/equipment or task to match Walter’s abilitiesMaking the best person-environment fit – focus on matching Walter’s abilities with the environment or task which is most enabling.Aim to reduce occupational performance issues that may result from an impairment, to enable participation(Curtin, 2010).The process of offsetting or concealing a psychological difficulty by developing in another direction

The aim of this approach is that patients will achieve their rehabilitation goals and experience their lives as being good qualityInitially requires some thought and careful actions, gradually becomes more automaticThe presence of this physical rehabilitation doesn’t necessarily mean that the patient’s psychological and emotional rehabilitation has happened, this frequently takes longerNot all patients achieve this psychological rehabilitationStoma care is most helpful when it enables the patient to achieve all of the 3 stages

Quality of life and PROMs are now frequently being used as secondary end-points in clinical trials of cancer management. However, some investigators continue to use non-disease-specific generic methodology for this purpose. The treatment of colorectal cancer leads to very specific side effects relating to bowel function and activities of daily living. The Guideline Development Group (GDG) therefore believes that colorectal cancer-specific patient-reported outcome measures should be developed to standardise the interpretation of quality-of-life reporting as a secondary end-point in future clinical trials in colorectal cancer. Reviewing the evidence for this guideline highlighted the lack of data on patient perspectives on all aspects of treatment. The GDG agreed that it was crucial that these data were collected and therefore recommended that colorectal cancer specific PROMs be developed to inform what patient perspective data should be collected in future NCRN clinical trials.

Our vision is to put our patients first while striving to deliver the best quality healthcare. To achieve this we focus on seven strategic goals, identified as critical to making our vision real.Our goals were developed, as part of a five year strategy, following extensive consultation with staff, the public and health partners. They are:To offer patient centred services by providing high quality, responsive, accessible, safe, effective and timely care.To promote and improve the quality of life of our patients.To strive towards excellence in the services and care we provide.To be the provider of choice for local patients and GPs.To listen to, support, motivate and develop our staff.To work with partner organisations to improve the health of local people.To maintain financial stability enabling the Trust to invest in and develop services for patients.Value the autonomy and uniqueness of the personDignity and respect must be central conceptsChoice must be enabled by the sharing of adequate informationTrust and the establishment of the therapeutic relationship is crucial to positive outcomesEncourage participationEmpowerment (Sumsion, 2010)

Getting the balance right between giving the patient enough time to recover but also leaving enough time to complete sufficient practice changes before discharge to gain basic expertise is not always easy (role for OT and physio/TA’S during recovery period – inpatient/outpatient?)Our care should also involve strategies to help patients manage loss and change as well as the practicalities of learning to live with a stoma is important (Breckman 2005)

2.
Learning Outcomes Brief explanation of the meaning of ‘stoma’ and causes of bowel cancer Review bowel cancer statistics and importance of screening Gain an overview of a specific patient’s experience pre/post operatively (bowel surgery) Review guidelines and evidence to support practice in stoma care and assessment of quality of life Consider opportunities for the acute therapy team to enhance the patient experience and their quality of life, promote recovery and decrease length of stay Summary & conclusion Questions

3.
StomaFrom classical Greek meaning ‘Mouth’ ‘Artificial opening’ (Black 2000) There are approximately 100,000 people in the UK with a stoma (Windsor and Conn 2008)

4.
Causes of Bowel Cancer High intake of red and processed meat will increase the chances of developing bowel cancer whereas a diet rich in fibre will reduce your risk Around 13% of bowel cancers in the UK are linked to overweight or obesity Research has shown that drinking as little as 10g/day of alcohol (around 1 unit) can increase the risk of bowel cancer Smoking increases the risk of bowel cancer People with a first-degree relative with bowel cancer are at twice the average risk of developing it themselves People with diabetes, ulcerative colitis or Crohns disease all have an increased risk of bowel cancer Being physically active reduces risk of colon cancer (Cancer Research UK 2011)

5.
Bowel Cancer UK Incidence Statistics Approximately 110 new cases of colorectal cancer are diagnosed daily The third most common cancer in women after breast and lung, third in males after prostate and lung In 2008 - 39,991 new cases of large bowel cancer registered: two- thirds (25,551) in the colon and one-third (14,440) in the rectum (Cancer Research UK 2011; NICE 2011)

6.
Bowel Cancer UK Incidence Statistics Bowel cancer is the third most common cause of cancer death among men (11% of all male cancer deaths). It is the third most common cause of death among women (10% of all female cancer deaths) The lifetime risk for men of being diagnosed with colorectal cancer is estimated to be 1 in 15 and for women 1 in 19 In 2009, there were 15,908 deaths from bowel cancer Bowel cancer mortality rates have overall decreased: For men, European age-standardised mortality rates were 35% lower in 2007-09 than in 1971- 73. For women, rates were 47% lower in 2007-09 than in 1971-73 (Cancer Research UK 2011)

7.
Average number of new cases per year and age-specific incidence rates per 100,000 population (UK)

8.
The importance of bowel screening Has been shown to reduce the risk of dying from bowel cancer by a quarter in people who are screened in England Most cases of colorectal cancer develop slowly over a number of years from adenomas, or benign polyps, which can transform into malignant adenocarcinomas. This provides the opportunity for screening to detect and treat benign polyps before malignant transformation occurs Can detect colorectal cancers at an early stage when survival rates are highest Those who attend screening have a 25% reduction in their risk of dying from colorectal cancer (Cancer Research UK 2011)

9.
Survivorship Five-year survival rates for male rectal cancer rose from 25% in the early 1970s to 51% in mid 2000s and from 27% to 55% for female rectal cancer These improvements are a result of earlier diagnosis and better treatment but there is still much scope for further progress Ten-year survival rates are only a little lower than those at five-years indicating that most patients who survive for five years are cured from this disease Patients who are diagnosed at an early stage have a much better prognosis than those who present with more extensive disease Bowel cancer incidence is generally higher in populations with ‘westernised’ diets and these populations also tend to have a higher proportion of overweight and obese people and lower levels of exercise (Cancer Research UK 2011)

19.
Analysis of Walter’s occupational performance‘Occupational performance analysis is a structured evaluationprocess that uses observation of an individual to identify anddefine factors that support or hinder occupational performanceand prevent that person from being a full participant in life’(Chard, 2010 p161)

23.
Assessment tools There are limited quality of life evaluation tools (Baxter et al 2006)1994 – Major quality of life international study using the Quality of Life Index (QLI) developedby Padilla and Grant (1985) - 16 countries 5289 patients recruited by stoma care nurses Patients completed a questionnaire 4 times in first year (discharge, 3, 6 & 12 months). The following year, one questionnaire at 18 & 24 months (voluntary basis)Findings: Showed change with time – biggest improvement between hospital discharge and 3 months (patients generally enjoyed a better quality of life) Those with good relationship with a stoma nurse after discharge had a significantly higher QOL than those who had a poor relationship Changing appliances - most patients had moderate confidence at hospital discharge. Those high in confidence had a higher QLI score. At 3 months, those with decreased confidence had a decrease in QLI scoreHelping to increase patients’ confidence in changing their appliance has a positive effect onQuality of life (Black 2000)

27.
Supporting role & rehabilitationOn the road to rehabilitation, most patients go through at least three stages :-1. Learn to basically care for their stoma and manage their equipment2. Complete with stoma, engages in activities of daily living they regard as part of their normal lifestyle3. Report feeling ‘back to normal’ or ‘being myself again’. The stoma is experienced as an integral part of the person instead of being separate or added onto themOur care must be relevant to our patients’ needs and also promote theirlonger-term psychological and physical rehabilitation (Breckman 2005)

28.
NICE Guideline Colorectal Cancer (2011) Patient-centred care – Take into account their needs and wishes; involve family and carers with consent; informed decisions; good communication Before surgery, offer all patients information about the likelihood of having a stoma, why it might be necessary and how long it might be needed for Ensure a trained stoma professional gives specific information on the management and care of stomas Quality of life - Colorectal cancer-specific patient-reported outcome measures (PROMs) should be developed for use in disease management and to inform outcome measures in future clinical trials

29.
‘The essence of successful stoma care is knowing,valuing and working with each patient as an individualhuman being. Their physical and psychological needs,goals capabilities and resources can then be used tohelp them to move from feeling and acting as a ‘stomapatient’ to being a person engaged in their normallifestyle who happens to have a stoma’(Breckman 2005)

30.
Summary: Getting the balance right The quality of pre-operative preparation can contribute greatly to patients quality of life and acceptance of their stoma The presence of any stoma, either permanent or temporary, affects patients’ lives, therefore carefully planned siting is critical to promote independence in self-care Psychological care is important to help patients to form positive attitudes towards their new form of bowel elimination and changes to their body image Patients are discharged very soon after surgery and this restricts the time available to help them gain adequate knowledge and skills to manage self-care at home (Black 2000, Borwell and Breckman 2005)

31.
Conclusion The impact of rectal surgery goes well beyond the physiological changes a person will experience With the appropriate knowledge, skills and sensitivity, we as health care professionals can help our patients to make the transition from despair to adjustment and rehabilitation, ultimately enhancing their quality of life and promoting recovery (Winney 2005)